Kings Daughters Community Health & Rehab

In the surveyor’s words

From the most serious findings on record at Kings Daughters Community Health & Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF610Apr 17, 2024

  Based on staff interview, resident interview, and facility documentation review, the facility staff failed to prevent further potential abuse, neglect, or mistreatment, while investigations were in progress, and the facility staff lacked the knowledge of the need to protect the resident if abuse is reported and/or witnessed. The facility conducted inadequate investigations and removed protective measures that were implemented following the allegation prior to a conclusion being reached regarding the abuse allegations, which had the potential to expose residents on 3 of 3 nursing units to abuse. Immediate Jeopardy and substandard quality of care were identified. […]

• Immediate jeopardy, patternF600May 15, 2026

  Based on staff interviews, resident interviews and record reviews, the facility failed to protect residents from neglect. The facility failed to ensure licensed nursing services were available on the [NAME] Wing nursing unit from approximately 7:47 p.m. on 1/31/26 until 7:00 a.m. on 2/1/26. During this period, 39 residents were without access to licensed nursing assessment, medication administration, monitoring, physician notification, and nursing intervention. As a result, Resident #6 (R6), Resident #7 (R7), and Resident #8 (R8) experienced untreated pain, delayed or missed medications, anxiety, insomnia, and psychosocial distress. This deficient practice constituted neglect and resulted in Immediate Jeopardy. […]

• Immediate jeopardy, patternF725May 15, 2026

  Based on staff interviews, resident interviews, and facility documentation reviews, the facility staff failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident affecting 39 residents on the [NAME] Wing. Specifically, the facility failed to ensure licensed nurse coverage on the west wing, resulting in one of the three nursing units operating without a licensed nurse available to administer medications or provide nursing oversight for approximately 12 hours. This deficient practice resulted in the identification of immediate jeopardy (IJ), and subsequent substandard care. […]

• Immediate jeopardy, patternF692Apr 17, 2024

  Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement interventions to ensure that 4 residents (Resident #14, Resident #13, Resident #3, and Resident #12), in a survey sample of 48 residents, maintained an acceptable parameter of nutritional status and as a result, all 4 experienced insidious, severe weight loss that was unplanned resulting in immediate jeopardy being identified. The findings included: On 3/19/24 at approximately 12:05 p.m., an interview was conducted with the Registered Dietician (RD), who was in the dining room. The RD reported that he comes weekly and is at the facility for 8 hours. […]

• Actual harm, patternF697May 15, 2026

  Based on staff interviews, resident interviews, clinical record reviews, and facility documentation reviews the facility staff failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This deficient practice resulted in harm for three residents, Resident #6 (R6), Resident #7 (R7), and Resident #8 (R8) out of a survey sample of nine residents. […]